The problem with proposing a new accident investigation model is showing that the one we have is inadequate. The paper claims this:
"However, a review of accident reports utilizing a more robust accident model reveals that many of the reports completely missed the actual factors that led to the accident." The support for this is:
- a reference to Nancy Leveson: Engineering for a Safer World. I've seen the refrenced section in the draft version, and it's basically a very short summary of three other studies.
- a reference to an analysis of Comair flight 5191, which criticzes the NTSB report thus: "The alternative, to manage performance and to control the sources of performance variability, is not considered." This seems contrafactual, since three of the four main recommendations adress exactly that: "cockpit moving maps or runway alerting systems" help performance management, and "airport surface marking standards" and "ATC policy changes" aim at reducing variability, as I understand it.
- a discussion of the NTSB report on the 1994 accident of USAir 1016 in Charlotte, which concludes: "That would push the entire investigation towards examining how to better provide accurate information to flight crews so they could make informed decisions." The point falls somewhat flat, as the report gives a lot of weight to these issues in its analysis of probably cause and recommendations. Both the lack of accurate weather information being provided as well as the organizational causes for this lack are being addressed in this report.
It's not convincing me that the existing NTSB reports are deficient.